In those with posterior element pathology, pain is reproduced in the back when the patient hyperextends, while standing on one leg. The Fitch test includes rotation, as well as one-legged hyperextension and may be more sensitive.

Examiner places thumb on PSIS and the other thumb on the midline of sacrum at similar level in standing patient. They observe the relative movements of the thumbs as the patient flexes the hip more than 90°. The inominate bone is expected to rotate posteriorly and, hence, the thumb on PSIS should move caudally. The contralateral inominate movement can also be assessed and should not move caudally.

A mark is made at the level of the posterior iliac spine on the vertebral column (level of L5). The examiner places one finger 5cm below this mark and another finger 10cm above the mark. The patient is then instructed to touch his toes. If the increase in distance between the two fingers on the patients spine is less than 5cm then this indicates restricted lumbar flexion.

General problem—degenerative changes appear in asymptomatic from early age.

Routine AP and lateral specialized oblique.

Technetium-labelled injection is taken up in areas of increased osteoblastic activity demonstrating increased metabolic activity in bone. Detected by gamma camera. Reveals stress fractures (i.e. spondylolysis), but also epiphyses and metaphyseal bone plates of young.

Allows visualization of bony configuration and good visualization of paraspinal soft tissues.

An injection of radio-opaque dye into the spinal canal reveals an outline of the spinal cord and nerve roots on subsequent plain X-rays. This can reveal nerve root compression, though not its cause (i.e. prolapsed disc, osteophyte or tumour).

Myelography is combined with CT technology for even greater detail.

Injection of radiopaque dye into the disc space under pressure—pain response assessed.

Consider forces involved and take history from the patient and witnesses. Review video if available.

Examine carefully to exclude injuries that could produce instability (threaten neurological structures).

Though ‘airway’ is a priority in an unconscious player, the cervical spine should be protected by employing a jaw thrust in preference to the head tilt-chin lift maneouvre. Inadequate immobilization in transporting player from pitch could worsen clinical condition!

When to immobilize?

Transportation should be on a spinal board by trained personnel to ensure immobilization in position athlete was found. In general, equipment such as helmets should only be removed by those trained to do so.

Cervical spine injury and potential instability should be presumed in anyone who is unconscious after head injury. The cervical spine will need assessment by cervical spine X-ray and CT of entire neck.

A desiccated disc with tears may give local pain.

In disc herniation (or ‘slipped disc’), the nucleus pulposis extrudes through a tear in the annulus fibrosis most commonly at L4/L5 and L5/S1. They occur most often in the 5th decade of life, although up to 2% occur in those under 18yrs. Such herniation may press on the nerve root causing leg pain (called ‘sciatica’), numbness and weakness. Pain may also be generated by the release of inflammatory molecules (e.g. tumour necrosis factor-alpha) and is known as ‘chemical radiculitis’.

Cervical disc herniation occurs most often in the lower cervical spine and is a cause of pain in neck, arm, or head. Numbness and weakness may occur. Thoracic disc herniation is rare, but may be a cause of chest or abdominal pain.